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Andrew Lyons-Home Based Primary Care: Bridging the Gap for Chronic Palliation Between Restoritive Care and End Of Life Care
 

Andrew Lyons-Home Based Primary Care: Bridging the Gap for Chronic Palliation Between Restoritive Care and End Of Life Care

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2014 Jewish Home Lifecare Palliative Care Conference: It's Not the Place, It's the Practice

2014 Jewish Home Lifecare Palliative Care Conference: It's Not the Place, It's the Practice

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    Andrew Lyons-Home Based Primary Care: Bridging the Gap for Chronic Palliation Between Restoritive Care and End Of Life Care Andrew Lyons-Home Based Primary Care: Bridging the Gap for Chronic Palliation Between Restoritive Care and End Of Life Care Presentation Transcript

    • Home Based Primary Care Bridging the gap for chronic palliation between restorative care and end of life care JHLC – Geriatric Palliative Care conference November 12, 2013 Andrew Lyons, MD Medical Director
    • Home Based Primary Care
    • The American Academy of Home Care Physicians (aahcp.org)  For the period of year 2000-2030 the number of Americans with chronic conditions will increase by 37%  125 million to 171 million individuals  Costs associated with Care of Chronic Illness will rise exponentially  High cost, chronically ill beneficiaries   Fill an average of 20 different prescriptions per year  Account for 76% of all Hospital Admissions   See an average of seven different Physicians per year Are 100 times more likely to have a preventable hospitalization compared with a non chronically ill population A small percentage of Medicare Fee for Service Beneficiaries consume the majority of costs    Top 7% - 53%, Next 5% - 16%, Next 12% - 17% In aggregate, the top 24% consume 84% of costs 80% of Medicare Spending is for people with 4+ Chronic Illnesses 3
    • What Patients Value  Personalized Care  Access to their Physicians  Autonomy to make Decisions  Continuity of Care  ER and Hospital Avoidance  Advanced Directives for Medical Care  Relief from worry  Protection from catastrophic costs  Chronically ill patients are not price sensitive consumers 4
    • The Merry Go Round  Acute Exacerbation of Chronic Illness  ER evaluation and Hospital Admission  3 Day Length of Stay qualifies patient for “post acute” care  Sub Acute Rehabilitation Stay (restorative?)  Non Physician Home Care Services  Primary Care Provider awaits patient back in office  Chronic Illness Persists  Acute Exacerbation of Chronic Illness  “Sicker and quicker” discharges  Hospital directive to reduce LOS, adhere to DRG period  Care Transitions between Hospitalist and PCP  Treatment initiated as Inpatient not complete  Need for restorative rehab services arises  Need for supportive care is identified 5
    • Factors Affecting Re-Hospitalization Rates  NEJM 2009 – Medicare Beneficiaries  90% of rehospitalizations within 30days are unplanned  Targeted interventions at time of discharge are superior to relying upon community resources  Hospital and MD collaboration is essential  Post surgical patients benefit from Medical coordination prior to procedure  Wide State to State variability  Lack of follow up with PCP in majority of cases  Medication reconciliation requires a prescriber engaged in the care of the patient  Home Care services work best with PCP cooperation and support  Post Acute Care period is great opportunity to establish Advanced Directives  NYS has earned distinction for readmissions 6
    • Policy Initiatives for Primary Care  PPACA – Expanded coverage, expanded costs   Primary care focused on symptom management   Primary care focused on Prevention Evidence based treatment and outcomes HIT incentives    EMR subsidies for MU certified systems ePrescribing incentives and penalties Accountable Care Organizations    Lump sum payment and incentives tied to outcomes Adherence to “quality” measures Medical Home Model    Primary Care Development Corporation National Committee on Quality Assurance (NCQA) Primary Care Incentives  10% bonus for primary care E&M codes and HPSA bonuses  Loan forgiveness – serving at FQHC sites  G code/CPT Codes for Transitional Care Coordination 7
    • The House Calls Model  Focused upon the sickest, most frail high cost beneficiaries  Superior access to Primary Medical Care  Proper engagement with necessary Home Care entities  Preferred care for the patients, consistent with their values  Low cost compared with the Merry go Round  Delivers appropriate care without imposing tone of austerity  Only effective way to deliver appropriate Transitional Care  Prescriber becomes the care coordinator  Lab, xray, ultrasound diagnostic services in the home  Point of care lab services in the home  The Primary Care of the Future because it retains what was good about the past.  Data from VA program over 40 yrs has been used to influence recent CMS pilot studies: 24% reduction in overall costs, 62% reduction in inpatient days http://www.iahnow.com/IAHcostsavings.htm 8
    • Payer Models for House Call Programs  Medicare   Primary Care Bonus   Fee for service rates above office visits Home Care Certification and Care Plan Oversight Independence at Home – “Medical Home at Home”   Care Coordination Fee and Gain Sharing   2012 Demonstration Project (PPACA) Separate and apart from ACO concept Medicaid   Primary Care fees scheduled to rise under PPACA to Medicare rates Managed Care  Medicare Advantage  Dual Eligible Special Needs Plans (ISNP’s, IESNP’s)    HCC Scores, HEDIS Measures, STAR ratings Capitation Concierge Private Pay  Retainer based + Out of Network Insurance 9
    • Outlook for Growth  Huge unmet need (10,000 Americans age in to Medicare daily)  Patients value this model  Payers are beginning to value this model   Central planning and care management can be enhanced   Only for high cost beneficiaries or initial HCC risk scores Complexity of conditions requires longitudinal intervention Hospitals may value this model   Part of strategy to avoid readmission and for ER decompression Home Care companies do value this model  An engaged PCP is frequently missing from their care model  The House Call PCP helps their model work better  No comparable program for Primary Care access and cost containment exists  Government payers are supporting this model   House Call E&M codes qualify as Primary Care Will require infrastructure support to maintain standards for quality and outcomes measures (safe harbor partnerships?) 10